ORIGINAL ARTICLE

Giant prosthetic reinforcement of the visceral sac:

the Stoppa groin hernia repair in 234 patients
Hemmat Maghsoudi, Ali Pourzand

From the Department of Surgery,

BACKGROUND: Recurrent and complex bilateral inguinal hernias are Tabriz University of
associated with a high recurrence rate. Giant prosthetic reinforcement Medical Sciences,
of the visceral sac (GPRVS) is popular in America and Europe, but there Faculty of Medicine
are no prospective data from Iran. Tabriz, Iran
PATIENTS AND METHODS: From 20 March 1995 to 20 March 2003, 234
patients (227 men and 7 women) with 420 inguinal hernias (186 bilateral Correspondence to:
and 48 unilateral) underwent repair using a large polyester mesh based on Hemmat Maghsoudi, MD
Stoppa`s preperitoneal technique. Mean age was 60 years (range 25 to 88) e Sina Hospital
and 44.8% had one or more comorbid conditions. In 154 instances, the re- Azadi Street, Tabriz, Iran
lapsed hernia had already been operated once or twice for recurrence. Tel: 98-411-336-1434
RESULTS: Mean hospital stay after surgery was 2.2 days (range 1-13 Fax: 98-411-541-2151
days). The mean operative time was 45 minutes (range 30-75 minutes). maghsoudih@yahoo.com
General complications were one case of upper gastrointestinal bleed-
ing, one case of ileus and one case of atelectasis. Local complica- Accepted for publication:
tions consisted of three local seroma formations. In no instance was February 2005
postoperative neuralgia, chronic pain or testicular atrophy, mesh
infection or death reported. Follow-up was obtained in all patients. Ann Saudi Med. 2005;25(3):228–232
The recurrence rate was 0.71% (3 of 420) per inguinal repaired or
0.85% (2 of 234) per patient. Factors predicating a high risk for recur-
rence included large hernia size (>5 cm), failure of one or more previ-
ous repairs (65.8%, 154 of 234), chronic cough and associated lower
abdominal hernias.
CONCLUSION: GPRVS is anatomic, sutureless, tension-free and the ab-
solute weapon to eliminate all type of groin hernias. No other technique
produces better results for the repair of recurrent and re-recurrent groin
hernias.

R
ecurrent and complex inguinal hernias are associated with a
high risk of recurrence. A recent review indicates that first-time
recurrent hernia repair fail in 1% to 30% of cases, that second-
time recurrent repairs do so at the rate of 3% to 35%, and third-time
or more repairs fail in 50% of cases.1 Reasons for these dismal results
include failure to identify the patients and factors affecting recurrence
such as chronic obstructive pulmonary disease, large size and weak
fascial structures. In addition, the use of anterior repair for recurrences
requires extensive dissection, often including the enlargement of an
already large defect and the use of scarred and devascularized tissue
under tension for the repair.
Stoppa et al2,3 first described a technique aimed at eliminating her-
nias of the groin by reinforcing the peritoneum with a giant polyester
mesh. With this giant prosthetic reinforcement of the visceral sac
(GPRVS), the mesh acts as an artificial endoabdominal fascia and

228 Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals

 STOPPA GROIN HERNIA REPAIR
prevents visceral sac extension through the myopec-
tineal orifice where all groin hernias begin.2
ere is consensus on the use of a prosthetic
mesh for the surgical treatment of recurrent groin
hernia, bilateral groin hernia, complex hernias and
connective tissue disease with groin hernia. is
article is a prospective evaluation of 234 consecutive
GPRVS used to repair recurrent or complex bilateral
inguinal hernias.
Patients and Methods
We prospectively evaluated patients undergoing bi-
lateral or unilateral Stoppa groin hernia repair over
the period from 20 March 1995 to 20 March 2003
with particular reference to indications, postopera-
tive hospital stay, complications, and recurrence. e
criteria for selection were recurrent and re-recurrent
hernias (unilateral or bilateral) or primary bilateral
hernia with associated risk factors for recurrence,
including chronic cough, connective tissue disease,
or other lower abdominal hernias. e repairs were
performed at Sina hospital, Tabriz University of
Medical Sciences, Tabriz, Iran. Follow-up was
obtained by examination at clinic. Follow-up ex-
amination was scheduled in all patients from 0 to
96 months.
Surgical Technique
e technique developed by Stoppa was used with
some minor modifications.2-6 A urinary catheter was
positioned before surgery in all patients. Prophylactic
intravenous antibiotics (cephazolin 1 gram every 6
hours) were administered in all patients before, dur-
ing, and after the procedure, until the drains were
removed.
e procedure is performed under general an-
esthesia or spinal anesthesia. A midline incision
extends from 2 cm below the umbilicus to 1 cm
above the symphysis pubis. e preperitoneal space
is entered with blunt dissection aided by sharp dis-
section when the peritoneum is scarred from prior
operations (appendectomy, herniorrhaphy, pros-
tatectomy or lower abdominal laparotomy). e
dissection includes the retropubic space of Retzius
and Bogros, and continues laterally, dissecting the
posterior portion of the rectus abdominis muscle on
the far side of the operator, proceeding behind the
epigastric vessels, progressing to the retroinguinal
space and further exposing the iliopsoas muscle.
Direct hernias are identified and reduced. Indirect
defects can be divided and the proximal peritoneum
oversewn, leaving the distal peritoneum in place un-
Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals
dissected and attached to the cord. In sliding indirect
hernias, the sac is dissected from the cord structures.
e spermatic cord and the gonadal vessels are pa-
rietalized by dissecting them from their peritoneal
attachment to allow them to lay tension-free in the
posterior pelvis. is step averts the need for mesh
splitting. e polyester mesh (Mersilene, Ethicon) is
fashioned as a chevron, and placed in the preperito-
neal space with long clamps. e size of the prosthe-
sis is measured on the patient. e width equals the
distance between the anterior superior iliac spines,
and vertically measures the distance between the
umbilicus and the symphysis pubis plus 6 cm. In
obese patients, the mesh should be several centi-
meters wider than the interspinous dimensions. e
mesh is held in place without the need for fixation
since the intra-abdominal pressure forces the mesh
to lay flat between the peritoneum and the fascial
layers. e mesh is oriented so that it stretches trans-
versally. e assistant retracts the parietal wall while
the surgeon depresses the peritoneal sac with the left
hand, pulling toward him or her to open the parieto-
peritoneal space. e patient is in the Trendelenburg
position to facilitate exposure. First, the inferior mid-
line clamp is placed in the space between the pubis
and bladder (Retzius space), then the inferior lateral
clamp, and then the lateral angel clamp (over the
iliac vessels). Finally, the upper lateral clamp extends
the length as far as possible to unfold the prosthesis
laterally. Each time a clamp is inserted, the assistant
immobilizes it until the operator releases the visceral
sac, abdominal wall retractor, and the clamp is re-
moved. e process is repeated on the opposite side.
e patient is placed in the reversed Trendelenburg
position, and the clamps are removed. e mid-por-
tion of the superior border of the prosthesis is then
sutured with a single stitch of absorbable suture to
the posterior rectus sheath. None of the hernial
defects were repaired. Closed suction drainage was
positioned in all patients and was removed after 24
to 48 hours. Eight hours following the procedure,
patients received clear liquids and were advanced to
regular diet as tolerated. Patients without comorbid
conditions were discharged after 24 hours of obser-
vation if they could void and tolerate liquids. Closed
suction drainage eliminates seromas and hematomas
and is not necessarily an indication for hospital
admission. Patients return for follow-up one week
postoperatively. Following the procedure, patients
were not restricted in their activity but were encour-
aged to return to their previous lifestyle without
limitation as soon as pain or discomfort permits.
229
 STOPPA GROIN HERNIA REPAIR

Results Table 1. Type of groin hernias in 234 patients with Stoppa groin
hernia repair.
A total of 420 inguinal hernias (186 bilateral, 48
unilateral) were repaired in 234 patients (Table 1). Type of groin hernias Number
ere were 227 men (97%) and 7 women (3%). e
Bilateral indirect inguinal hernia 55
mean age of patients was 60 years (range, 25 to 88).
One hundred thirty-seven patients were older than Bilateral direct inguinal hernia 93
60 years, including seven older than 80 years (Figure Bilateral inguinal hernia (right: direct, left: indirect) 16
1). Concomitant medical problems were observed in
Bilateral inguinal hernia (right: indirect, left: direct) 22
105 patients (44.8%). Cardiovascular diseases were
the most frequent (65 cases), followed by urologic Unilateral hernia 48
diseases (mainly benign prostatic hypertrophy, 20
cases) and pulmonary diseases (20 cases includ-
ing bronchectasis, chronic obstructive pulmonary 35

disease, asthma, chronic cough and tuberculosis).

Risk factors predicating a high risk for recurrence 30

included a large hernia size (>5 cm) in 34% (80

25
of 234), failure of one or more previous repairs in
65.8% (154 of 234), and associated lower abdominal 20
hernia in 9.8% (23 of 234). In the 234 patients with Percent
420 groin hernias, 80 hernias were primary, 143 were 15

recurrent and eleven re-recurrent.

GPRVS was completed in all 234 patients, and 10

no patient required conversion to another technique.

5
Bilateral GPRVS was used in 186 patients to repair
372 hernias, of which 212 were recurrent and 160 pri- 0
mary groin hernias. Unilateral GPRVS via a subum- 21-30 31-40 41-50 51-60 61-70 71-80 81-90

bilical incision has been used to manage 48 complex Age (years)

and recurrent hernias of the groin. General anesthesia
Figure 1. Age distribution in 234 patients who underwent
was used in 51 patients, and spinal anesthesia in 183 Stoppa groin hernia repair.
cases. e mean operative time was 45 minutes (range
30-75), and there was no complication related to an-
esthesia (Table 2). ere were 216 right-sided hernias 45

and 204 left-sided hernias. No anterior counterinci- 40

sion was required. All patients were repaired with
35
polyester mesh (Mersillene, Ethicon).
e mean length of hospital stay was 2.2 days 30

(range, 1-13 days). Ninety-seven patients without co- 25

morbid conditions were discharged 24 hours after the Percent
operation (Figure 2). Upper gastrointestinal bleeding 20

from peptic ulcer, which required several blood trans- 15

fusions and a prolonged hospital stay (13 days), oc-
10
curred in one patient. ere was one case of ileus and
one case atelectasis. Local complications consisted of 5

three cases of seromas in the dead space of the hernia 0

sac, which were resolved with needle aspiration with- 1 2 3 4 5 6 13

out delaying recovery or discharge (Table 2). Days

No neuropathies, chronic pain or testicular atro-
Figure 2. Postoperative hospital stays in 234 patients.
phies occurred. No deep infections occurred in the
patients who had polyester prosthesis implanted,
and no polyester prosthesis had to be removed. e
recurrence rate was 0.71% (3 of 420) per inguinal re-
paired or 0.85% (2 of 234) per patient. e latter two

230 Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals

 STOPPA GROIN HERNIA REPAIR
Table 2. Mean operative time and postoperative complications
in 234 patients with Stoppa groin hernia repair.
Number
Mean operative time
30 minutes 92
45 minutes 71
60 minutes 50
75 minutes 21
Postoperative complications
Ileus
Upper gastrointestinal bleeding
Atelectasis
Seroma
Recurrence
recurrences occurred 6 and 4 months after repair,
respectively. Mean time off from work after surgery
was 2 weeks (range 1-3 weeks).
Discussion
e risk of recurrent herniation must be balanced
against the risks, the complexity and the magni-
tude of the hernioplasty. Some patients do not
want general anesthesia and others do not want
mesh.10,18,19,20,21 For primary inguinal hernias of all
types, anterior inguinal hernioplasty with the aid of
local anesthesia and without prosthetic reinforce-
ment will remain the first choice of surgeons and
patients because it is simple and safe and produces
acceptable results. It can be done in an ambulatory
surgical center in selected patients, and can be suc-
cessfully performed in even the most debilitated
patient, if necessary.
More recently, primary as well as recurrent her-
nias have been successfully repaired using prosthetic
material with the safe utilization of open or laparo-
scopic approaches. In recent commentary, Rutkow
stated that the recurrence rate has been the major, if
not sole, criterion on which the efficacy of any her-
niorrhaphy is judged despite the fact that over the
last half century, recurrence rates have been similar
regardless of which technique is used. In addition
to recurrence rates, socioeconomic factors, technical
difficulty, complication rates, short and long-term
postoperative discomfort, time of return to daily
activities should also play a role in the equation.
Nyhus12 points out that modern hernia surgery
should individualize the repair to each clinical
Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals
situation, and some would add, to each social and
economic circumstance. In this study, the GPRVS
was mostly used in a group of older patients, with
multiple medical problems as well as recurrent or
complex bilateral hernias. Miller13 and colleagues
demonstrated that the simultaneous repair of bilat-
eral inguinal hernias is safe and does not result in an
increased recurrence rate.
e posterior approach allows a bilateral ap-
proach through a single incision and reduces the risk
of nerve injury, neuralgia, ischemic orchitis, testicu-
lar atrophy and chronic pain. In this study, the choice
1
of GPRVS for primary bilateral inguinal hernias
1 was individualized. Primary bilateral hernias were
1 considered as complex if they were associated with
factors predicating a high risk for recurrence such
3
as multiplicity, large size or were associated with
2 comorbid aggravating factors (e.g., COPD) based
on the recurrence rate reported after traditional
hernia repair. e GPRVS takes advantage of the
unique properties of the polyester mesh: (1) it does
not encapsulate, thus minimizing the formation of
fluid collections; (2) it has no plastic memory and
adapts to the endopelvis; and (3) it induces fibrous
ingrowth preventing migration. e same material
(polyester) has a long track record of safety, and has
been used for many years in vascular surgery to re-
place major vessels.
e GPRVS was evaluated prospectively because
even though this technique is popular in America
and Europe, there are no prospective data from Iran.
e complication rate of 3% per patient repaired (one
major, 0.43% and 6 minor, 2.56%) is comparable with
other reports.2,15,21 ere were no mesh or superficial
wound infections. e mean length of stay (2.2 days)
reflects the large population of elderly patients with
complex medical and social situations. In comparison,
97 of 234 patients without comorbid conditions were
discharged after 24 hours of the operation. Overall,
the patients were very satisfied with the procedure.
e absence of limitation in the level of activity post-
operatively allowed all patients, including industrial
and agriculture workers, to return early to full activity.
is lack of restriction in activity is based on the safe-
ty provided by the wide tension-free mesh prosthesis,
which evenly distributes the intra-abdominal forces
against the lower abdominal wall (Pascal’s hydrostatic
principle). Large prostheses are kept in place by intra-
abdominal pressure; they need not be fixed or associ-
ated with a repair of the hernial orifice.
Recently, with the advent of laparoscopic
repair,8,12 the armamentarium of the surgeon has
231
 STOPPA GROIN HERNIA REPAIR

increased and so has the confusion as to which tech-
nique is best to use. In patients presenting with large
chronic or recurrent hernias, laparoscopy is often
technically challenging because the difficulties as-
sociated with reduction of the hernia or adhesions,
especially in cases where mesh has been previously
used. Prior abdominal interventions (e.g. appendec-
tomy) often complicate laparoscopic dissection of
the retroperitoneum. Laparoscopy uses smaller pros-
theses and requires mesh fixation with the attendant
risk of nerve injury. e technique of GPRVS with
large polyester mesh cannot be readily transferred to
laparoscopy because of the reduced size of the op-
erative field and limited exposure, and the need for
parietalization of the cord structures.
In our series, the 0.85% (2 of 234) recurrence
rate is lower than other studies using the GPRVS
technique7,11,14,15,16,17,18 and compares well with recur-
rence rates reported with other techniques. In the
experience of Stoppa et al,2 others, and our study
with GPRVS, all recurrences occurred within 6
months and were ascribed to technical failures. In
GPRVS, the replacement of the endoabdominal fas-
cia seals the inguinal, femoral, and obturator canals
as well as all other potential sites of weakness in the
lower abdomen. For this reason, late recurrences are
not reported. In contrast, recurrences after anterior
techniques accumulate over time, and long-term fol-
low-up is mandatory. In our study, 93% of patients
were followed up for 6 months or more, and late
recurrences in these patients were unlikely. Early in
the experience, the two recurrences occurred 6 and 4
months after the procedure and were due to techni-
cal error.
In theory, recurrences after GPRVS are incon-
ceivable.21 Nevertheless, they occur. Although other
factors may be at play, most recurrences can be attrib-
uted to technical errors, most often related to the size
and placement of the mesh. No other hernioplasty
produces better results for recurrent and especially
re-recurrent groin hernias. For excellent results, the
mesh must be polyester that is correctly sized, shaped
and placed. Finally, the operation is easy and the dis-
section pleasing to all surgeons. Exceptional skill and
extensive experience do not appear necessary for
good results. e GPRVS is a safe and effective way
to treat selected patients with recurrent unilateral or
complex bilateral inguinal hernias.

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232 Ann Saudi Med 25(3) May-June 2005 www.kfshrc.edu.sa/annals